Form 0920-XXXX Dog Exposure Questionnaire

Notes to Interviewer Questionnaire to be used for individuals who have had an isolate with the multidrug-resistant pattern associated with the outbreak.	Epi Info ID ________
Instructions in italics are for interviewer only. Do not read italicized words to person being interviewed. Administer questionnaire to the patient (or patient’s caregiver). Complete Section 1 before contacting the patient. Complete one form for every patient and complete as much information as possible. Thank you!

Dog Exposure Questionnaire

Form Approved

OMB Control No.:0920-XXXX

Expiration date: XX/XX/XXXX

Read aloud before interview: My name is [name] and I’m with [organization]. We are investigating an outbreak of diarrhea caused by the Campylobacter germ. Your participation is completely voluntary, and you can quit at any time. Any data we collect will be kept confidential, and your participation may help in the response and control of the outbreak. Do you agree to participate?

Section 1: Interview information (Complete before administering questionnaire)

PulseNet ID #: ___________________________

State/Local/Other ID #: ______________________________

Date of Interview: __ __ / __ __ / __ __ __ __ (If unknown, enter 99/99/9999) M M D D Y Y Y Y

Interviewer information

Name: 6.Contact phone number: (____) ______-_______

Agency:

Did the patient die? Yes No Don’t know 7a: Date of death: __ __ / __ __ / __ __ __ __ (If unknown, enter 99/99/9999) M M D D Y Y Y Y 7b: If the patient died, was it attributable to Campylobacter? Yes No Don’t know

Respondent was: Patient Parent Other, name and explain relation________________________

Section 2: Demographic Data: I’d like to begin by asking a few questions about the patient and the patient’s household.

What are your state, county, and zip code?

State abbr. _____ County ____________ Zip Code _____________

Patient’s age ________ Years Months Days

Sex: Male Female Unknown

How do you describe your/your child’s race (may select more than one)? White Asian Black/ African American Declined to answer American Indian or Alaska Native Native Hawaiian/Pacific Islander

How do you describe your/your child’s ethnicity? Hispanic Non-Hispanic Unknown Declined to answer

What is your/your child’s occupation or job? ________________________________________________________________

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB Control Number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX

Section 3: Clinical Information: Now I have a few questions about your/your child’s illness.

What date did you/your child first feel sick? I can wait while you get a calendar if you need to.

__ __ / __ __ / __ __ __ __ M M D D Y Y Y Y

Yes

Maybe

No

Don’t Know

Did you/your child or Were you/your child:

Have any diarrhea?

Hospitalized for this illness?

3a: If hospitalized, how many nights? ______

How many days did your/your child’s illness last? _______ days Don’t know Still Ill

Section 4A: Dog Exposure Details (At Home):Now, I have a few questions about any interaction you/your child may have had with dogs/puppies at home in the 7 days before illness began, which is from ___ ___ / ___ ___ / ___ ___ ___ ___ (subtract 7 days from onset date) to __ __ / __ __ / __ ___ ___ __ (onset date).

Yes

Maybe

No

Don’t Know

In the 7 days before you/your child became ill, did you/your child have a dog/puppy in the household? (If “no” or “don’t know” skip to Section 4B)

What was the age of the dog/puppy at the time of your/your child’s illness? <6 months 6 months - <1 year >1 year Don’t know

What is the breed or your/your child’s dog/puppy? Unknown Breed 1:_________________ Breed 2:_________________ Breed 3:____________________

In the 30 days before your/your child’s illness, was your/your child’s dog/puppy purchased from a pet store? (If “no” or “don’t know” skip to Section 4B)

At what store did you purchase your dog? Don’t know Store Name:__________________________ Location:_____________________________

When did you purchase your dog? __ __ / __ __ / __ __ __ __ Don’t know M M D D Y Y Y Y

Section 4B: Dog Exposure Details (Outside the Home): Just a few more questions about any interaction you/your child may have had with dogs/puppies outside of your home in the 7 days before illness began, which is from ___ ___ / ___ ___ / ___ _ (subtract 7 days from onset date) to __ __ / __ __ / __ ___ __(onset date).
Yes	Maybe	No	Don’t Know
				In the 7 days before your/your child’s illness began, did you/your child touch any dog/puppy in a pet store, at a friend’s house, or other location?
				In the 7 days before you/your child’s illness began, did you/your child touch any dog/puppy cages or other areas where dogs/puppies were present? (If “no” or “don’t know” to Questions 1 and 2, skip to Section 5)
				Where did you/your child have contact with a dog/puppy or its cages/areas in the 7 days before you/your child became ill? (check all that apply) Another person’s home Pet Store Other:_________________ Don’t know 3a. If at a pet store, please provide more information. Name of store: _____________________________ Address of store: ___________________________
				What was the age of the youngest dog/puppy you/your child were in contact with? <6 months 6 months - <1 year >1 year Don’t know
				What is the breed or your/your child’s dog/puppy? Unknown Breed 1:_________________ Breed 2:_________________ Breed 3:____________________
Do you/your child work or volunteer in a location where dogs are present such as a pet store or dog shelter? Yes No

Section 5: Comments: Is there any other information you would like to share about this illness or about contact with dogs/puppies?

That was my last interview question. Thank you very much for your time and assistance.

Please send completed questionnaires to CDC Enteric Diseases Epidemiology Branch, Attn: Dr. Mark Laughlin. Email: [email protected] Fax: 404-471-2620